Health Care System "In Pursuit of Excellence" Case Example

Ascension Health

October 2008

The Organization

Ascension Health is the nation's largest Catholic and largest non-profit health system, serving patients through a network of hospitals and related health facilities providing acute care services, long-term care, community health services, psychiatric, rehabilitation and residential care. The system employs more than 100,000 people and has health facilities in 20 states and the District of Columbia.

The organization's mission is: "Rooted in the loving ministry of Jesus as healer, we commit ourselves to serving all persons with special attention to those who are poor and vulnerable. Our Catholic health ministry is dedicated to spiritually centered, holistic care which sustains and improves the health of individuals and communities. We are advocates for a compassionate and just society through our actions and our words."

The Initiative: Access Leadership Planning Program

Ascension Health's "Healthcare That Leaves No One Behind" initiative includes a strategic goal of 100 percent access to care by 2020 for all people regardless of their insurance status in the communities served by Ascension Health facilities. As a part of this strategic goal, the "Access Leadership Planning Program" was launched in 2006. The program is a collaborative effort to improve access to the communities and serve as a voice for the voiceless, raising awareness about the health care access challenges faced by those served, particularly those who are poor and vulnerable, in order to promote and foster collaborative action to address challenges.

The Ascension Health Approach. Several years before the program was established 12 of the Ascension Health communities received federal grants to focus on improving access to care. While the communities made progress, the organization learned that the federal grants weren't enough. The complexity of the issue required accountability and ownership from top leadership and other safety net leaders in the community. As a result, the Access Leadership Planning Program makes access and coverage a critical component of leadership responsibilities, and recognizes that successes cannot be achieved without community collaboration and coalitions.

Establishing the Program. In 2006 Ascension Health set a three-year goal that the CEO of every one of its Health Ministries with acute care hospitals (67 acute care hospitals in total) have a written plan describing how they will work in collaboration with their community and other safety net providers to improve access to the uninsured. Ascension Health made access to care a top priority, so the Health Ministry CEOs understand that planning to ensure access to care for the uninsured is just as important as traditional business planning, such as capital acquisition or workforce retention.

To assist the CEOs in the establishment of a plan for their communities, each of the Health Ministries receive support from the system office through a team of consultants that work on-site to conduct a community needs assessment. The consultants then provide the assessment results to the Health Ministry leaders and assist them in developing a written plan.

The Five-Step Model. As a part of the program, the health system developed a five-step approach to help the Health Ministries develop their plan, working toward 100 percent access and 100 percent coverage for all. The steps are used as a guideline for all Health Ministry leaders as they develop an approach customized to their local needs.

1. Build a formal community-wide infrastructure, establishing leadership coalitions, shared information systems and catalyst funding. Collaboration is critical to success, and success is not about any one organization's individual role but rather the combination of all of the community's assets working together to achieve a shared goal. This requires identification of what the community needs and who needs to come to the table to meet those needs.2. Fill community service gaps that need to be addressed. These gaps are identified through the community needs assessment and vary in each community. Often the most significant gaps for the uninsured include dental care, access to pharmaceuticals, and mental health care. In addition, creating more primary care capacity is important.3. Establish care models that achieve improved outcomes, coordinating health care and creating a comprehensive system of care for uninsured patients. Each community's care models are unique to their community needs assessment, and often require creativity and collaboration. Some examples include establishing a chronic care model for diabetes and other chronic diseases, helping patients determine if there is health care funding they can apply for, and addressing infant mortality through "foot soldiers" in local neighborhoods that work with young women to ensure access to prenatal care and parenting classes.4. Collaborate with private physicians, encouraging them to volunteer as medical homes/specialists for the uninsured and underinsured. The engagement of individual physicians and the local medical societies is critical to success.5. Seek sustainable funding for the care model applied, which may come from state and local governments, local businesses and community partnerships. This requires getting the board energized and in the community building support, and a combination of board members and organizational leaders advocating in front of audiences like the city council, county commissioners and legislators.

Program Costs and Administration. While conducting the community needs assessment in each community does have a cost, the most significant costs are the work implemented as a result of the community needs assessment. This cost is unique to the specific needs and programs implemented in each community. For example, if a community establishes a community-wide pharmacy program there are significant costs associated with establishing the program infrastructure, purchasing technology, and subsidizing care.

In addition to individual community costs, the system employs staff that assists the CEOs and organizational leaders in their efforts. Five senior consultants work with the CEOs on-site, an equivalent of 2.5 FTEs. Each consultant is responsible for 5-6 Health Ministries.

The system office also employs five FTEs that work as a support team, helping the health ministry leaders with practical implementation of their local initiatives. Support such as assistance with best practices and providing additional materials specific to each local community's initiatives are most often provided via telephone and web conferences. For example, if a community-wide pharmaceutical access program is a high priority and the Health Ministry doesn't know how to get started, the support team will help with the process by providing information about what software is needed, and steps for launching the initiative.

Physician Involvement. Local physicians are very involved in the assessment and planning process in each community. Generally the chief medical officers, leaders in the local medical society, and employed and elected physician leaders all play a key role in the assessment process, as do primary care doctors and emergency room physicians. Once the community needs assessment is complete, the level of physician involvement varies depending upon the outcomes of the assessment. For example, in some communities one of the highest priorities is dental care, so those Health Ministries will work closely with local dentists.

Governance. The Ascension Health System board of trustees has approved this initiative and strongly supports the plan. In addition, each local Health Ministry is required to secure approval of their Access Leadership Plan by its own board of trustees. Often the plans are reviewed by the local boards two or three times before they are approved and adopted. Local boards are highly engaged in the work, including working with other community organizations to build collaboration and support.

Impact

To-date, 25 of the 27 Health Ministries of Ascension Health have completed their community needs assessments; the two remaining Health Ministries are scheduled to complete their assessments by June 2009. Despite the near completion of nearly all of the community needs assessments and the implementation of local initiatives in many of the communities, measuring the impact of the program has been challenging.

When the program first began, Ascension Health established a set of 8-10 specific outcome measurements with strict numerators and denominators so that the system could compare the results between the communities. However, collecting data for the measurements is not easy for all of the communities; while all are trying to collect the data, many are only able to collect some of the measures. In addition, each community has developed unified measurements for their specific programs. This allows them to track their own unique results, but the measurements are not comparable with other organizations in the system.

Calculating Return on Investment. Ascension Health is in the process of developing a set of "Return on Community Investment" tools for the Health Ministries to implement. The tools are Microsoft Excel® spreadsheets that help determine the costs and benefits of organizational efforts in terms of community value. While the costs are different for every Health Ministry, Ascension Health is seeking to determine a scientific way to measure a return on investment that will be comparable across the entire system.

Although the return on investment has not yet been quantified, anecdotal evidence shows that cost savings are already taking place. At the same time, this savings is masked by the rate of increase in the number of uninsured or underinsured in each community. Ascension Health expects the rate of increase of charity care and uncompensated care for Health Ministry hospitals to continue to grow faster than the savings generated from the program, causing the growth in charity care and uncompensated care costs to slow, but not decline.

Challenges Faced. Measurement of meaningful, comparable data has been difficult. The health system's initial approach with pre-determined measures was not successful because many of the organizations were not able to track all of the data, or the sample sizes were too small. This results in part because the patients tend to be more transient and difficult to track over time, and because no insurance companies are involved no claims data is available.

In addition to measuring success, the establishment of "care models" to help chronically ill patients manage their health care (the third step in the five-step model) has been more difficult than originally anticipated. While leaders thought this would naturally flow as a result of setting up care in local communities, this has been a challenge because patients are more transient and because it is expensive to implement. The health system is in the process of examining different models to determine what changes may be made in this area.

Advice for Organizations Implementing a Similar Program. Leadership readiness and commitment are critical to success. If the system office had simply sent out a mandate for the Health Ministry CEOs, they would have complied with the best of intentions, but they wouldn't have known how to go about it to be most effective. The individual organizations needed the financial resources and consulting assistance provided at the system level. Having adequate resources and support allowed the Health Ministries to develop new systems of care and make significant change in their communities.

Community readiness to address the uninsured is also essential. Community leaders must recognize that challenges related to uninsured and underinsured patients are a collective problem, and are a responsibility of the entire community. If the broader community does not share this mindset, and tends instead to "point fingers" about who is responsible for the uninsured, then the initiative will not be optimally successful. Conducting a community needs assessment helps identify the community's readiness. If the entire community is not ready to work together in collaboration, the program's initial approach may be on a smaller scale in partnership with a few select organizations until the effort gains momentum.

Value

While the actual cost savings and health benefits have not yet been measured on a system level, many of the communities have demonstrated success through their individual programs. In addition, the initiative has united the system's leaders around a shared goal of access and coverage for all, creating a shared sense of responsibility and the ability to share best practices.

Lessons Learned. The partnerships formed in each community are unique to that community. When the health system initiated the program leaders expected the partnerships to be approximately the same for each community, but they have since learned that all health care is truly local. Each community's needs are different, the organizations with presence in the community are different, and the political environment varies. For example, in some communities local governmental agencies play a significant role while in other communities the government has minimal involvement and private organizations (churches, health care providers and other non-profit organizations) have a more significant impact.

In addition, providing structure, support and training for the individual communities is critical. Many organizations are paralyzed by the magnitude of the uninsured problem; overcoming challenges to access and coverage is so overwhelming that they don't know where to start. By putting some structure to the program and providing consulting help, the individual organizations are able to get started and make an impact.